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Emergency Medicine Clinical Capabilities Checklist

 
Note: First Name, Last Name, Email Address, as well as Signature Name and Date Completed (at the bottom of the checklist) are required. All other fields are optional.
First Name Middle Name Last Name
Email Address
 
  Certifications  
 
BLS BLS Exp. Date ACLS ACLS Exp. Date
Yes No / / Yes No / /
 
ATLS ATLS Exp. Date ABLS ABLS Exp. Date
No / / Yes No / /
 
PALS PALS Exp. Date NRP NRP Exp. Date
Yes No / / Yes No / /
 
Scope of Practice
 
Do you feel comfortable covering Level I trauma setting? Yes No
Do you feel comfortable covering Level II trauma setting? Yes No
Do you feel comfortable covering Level III, usually rural setting? Yes No
 
Trauma Level I - Major trauma with in-house anesthesia coverage 24-hours a day; surgical, radiologic and other specialty consultation readily available
Trauma Level II - EM physician in-house 24 hours per day with specialty consultation available within 30 minutes
Trauma Level III - EM coverage available within 30 minutes (usually covered by community physician)
 
Check if you are comfortable performing the following:
 
ABEM Certified: Yes No
Date first certified Date most recently re-certified
/ / / /
 
ABEM Eligible: Yes No
Date first became eligible Expected date of completion
Written Exam		 Expected date of completion
Oral Exam
/ / / / / /
 
AOBEM Certified: Yes No
Date first certified Date most recently re-certified
/ / / /
 
AOBEM Eligible: Yes No
Date first became eligible Expected date of completion
Written Exam		 Expected date of completion
Oral Exam
/ / / / / /
 
Please list any procedures customary to your specialty training that you are not comfortable performing (maximum 254 characters)

You have 254 characters remaining
 
Work History
 
1. Hospital Name Dates of Affiliation (m/yyyy)
From: /   To: /
Trauma Level Rating* (or equivalent) Annual Volume % Adult % Peds Total EM Hours Logged Physician Coverage
S/D/T+
 
2. Hospital Name Dates of Affiliation (mm/yyyy)
From: /   To: /
Trauma Level Rating* (or equivalent) Annual Volume % Adult % Peds Total EM Hours Logged Physician Coverage
S/D/T+
 
3. Hospital Name Dates of Affiliation (mm/yyyy)
From: /   To: /
Trauma Level Rating* (or equivalent) Annual Volume % Adult % Peds Total EM Hours Logged Physician Coverage
S/D/T+
 
4. Hospital Name Dates of Affiliation (mm/yyyy)
From: /   To: /
Trauma Level Rating* (or equivalent) Annual Volume % Adult % Peds Total EM Hours Logged Physician Coverage
S/D/T+
 
5. Hospital Name Dates of Affiliation (mm/yyyy)
From: /   To: /
Trauma Level Rating* (or equivalent) Annual Volume % Adult % Peds Total EM Hours Logged Physician Coverage
S/D/T+
 
* Trauma Level I - Major trauma with in-house anesthesia coverage 24-hours a day; surgical, radiologic and other specialty consultation readily available
Trauma Level II - EM physician in-house 24 hours per day with specialty consultation avalable within 30 minutes
Trauma Level III - EM coverage available within 30 minutes (usually covered by community physician)
 
  Disclaimer  
 
The information I have given is true and accurate to the best of my knowledge. By clicking the submit button I hereby authorize Advantage Locums, LLC to release this Emergency Medicine Clinical Capabilities Checklist to facilities of Advantage Locums, LLC in relation to consideration of my employment.
 
Signature Name Date Completed
/ /
 
Save your work so you can update or complete it later Submit your information via email
 


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